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Washington DOH 422-064: Attending Provider Compliance

The attending qualified medical provider uses this form to show the Washington Department of Health that each step of the Death with Dignity Act (chapter 70.245 RCW) was followed before prescribing medication to end life. It records the oral and written requests, eligibility determinations, disclosures and counseling, the consulting and mental health evaluations, and the medication prescribed and how it was dispensed.

Who completes it

The attending qualified medical provider (physician, ARNP or PA) completes and signs the whole form. The patient's written request (DOH 422-063), the consulting provider's form (DOH 422-065) and any psychiatric or psychological form (DOH 422-066) are completed by others and attached.

Submitting and payment

How to submit it
Submit within 30 calendar days of writing the prescription, together with the attached forms, through DOH's REDCap online form, by fax, or by mail to the Center for Health Statistics.
Who pays
The DOH forms and instructions set no fee or billing code for this report.

Good to know

  • The second oral request must come at least 7 days after the first, and the prescription may be written no sooner than 7 days after the first oral request.
  • Mark one dispensing route: you dispensed directly and attach the Pharmacy Dispensing Record (DOH 422-067), or you delivered the prescription to a pharmacist personally, by mail, fax or electronically.
  • The Act gives immunity from civil and criminal liability and disciplinary action only for good-faith compliance, and DOH contacts providers when forms are missing information.
  • 2023 amendments let ARNPs and PAs act as qualified medical providers; the current form is the July 2023 edition.

Get the official form

Download the current version from the source each time; forms change without notice.

Attending Qualified Medical Provider Compliance

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

When is DOH 422-064 due?

Within 30 calendar days of writing the prescription for a lethal dose of medication. The attending provider sends it with the patient's written request (DOH 422-063 or a substantially similar form), the consulting provider's compliance form (DOH 422-065), and the psychiatric/psychological form (DOH 422-066) when an evaluation was performed.

Can Death with Dignity forms be submitted electronically in Washington?

Yes. DOH accepts the completed forms through its REDCap online form, available since July 2023, as well as by fax or mail. DOH says it keeps all information strictly confidential and releases only aggregate information on an annual basis.

Who is a qualified patient under Washington's Death with Dignity Act?

An adult of at least 18 who is competent, a Washington resident, and diagnosed with an incurable and irreversible disease expected to produce death within six months. DOH's instructions list a driver's license, voter registration, a mortgage or rental agreement, or a utility bill as common proof of residency.